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Clinical & Payment Policies | Ambetter Insured by Celtic
Políticas clínicas y de pago
Clinical Policies
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. All policies found in the Ambetter of Illinois Clinical Policy Manual apply to Ambetter of Illinois members. Policies in the Ambetter of Illinois Clinical Policy Manual may have either a Ambetter of Illinois or a “Centene” heading. Ambetter of Illinois utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter of Illinois clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Ambetter of Illinois. In addition, Ambetter of Illinois may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by Ambetter of Illinois. If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- Acupuncture (CP.MP.92) (PDF)
- Adopted Clinical Practice and Preventive Health Guidelines (CPG Grid) (PDF)
- Air Ambulance (CP.MP.175) (PDF)
- Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia (CP.MP.108) (PDF)
- Applied Behavior Analysis (CP.BH.104) (PDF)
- Applied Behavioral Analysis Documentation Requirements (CP.BH.105) (PDF)
- Articular Cartilage Defect Repairs (CP.MP.26) (PDF)
- Assisted Reproductive Technology (CP.MP.55) (PDF)
- Bariatric Surgery (CP.MP.37) (PDF)
- Behavioral Health Treatment Documentation Requirements (CP.BH.500) (PDF)
- Biofeedback (CP.MP.168) (PDF)
- Biofeedback for Behavioral Health Disorders (CP.BH.300) (PDF)
- Bone-Anchored Hearing Aid (CP.MP.93) (PDF)
- Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164) (PDF)
- Clinical Trials (CP.MP.94) (PDF)
- Cochlear Implant Replacements (CP.MP.14) (PDF)
- Concert Genetic Testing: Aortopathies and Connective Tissue Disorders (V2.2023) (PDF)
- Concert Genetic Testing: Cardiac Disorders (V2.2023) (PDF)
- Concert Genetic Testing: Dermatologic Conditions (V2.2023) (PDF)
- Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions (V2.2023) (PDF)
- Concert Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (V2.2023) (PDF)
- Concert Genetic Testing: Eye Disorders (V2.2023) (PDF)
- Concert Genetic Testing: Gastroenterologic Disorders (non-cancerous) (V2.2023) (PDF)
- Concert Genetic Testing: General Approach to Genetic Testing (V2.2023) (PDF)
- Concert Genetic Testing: Hearing Loss (V2.2023) (PDF)
- Concert Genetic Testing: Hematologic Conditions (non-cancerous) (V2.2023) (PDF)
- Concert Genetic Testing: Hereditary Cancer Susceptibility (V2.2023) (PDF)
- Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders (V2.2023) (PDF)
- Concert Genetic Testing: Kidney Disorders (V2.2023) (PDF)
- Concert Genetic Testing: Lung Disorders (V2.2023) (PDF)
- Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders (V2.2023) (PDF)
- Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay (V2.2023) (PDF)
- Concert Genetic Testing: Non-Invasive Prenatal Screening (NIPS) (V2.2023) (PDF)
- Concert Genetic Testing: Pharmacogenetics (V2.2023) (PDF)
- Concert Genetic Testing: Preimplantation Genetic Testing (V2.2023) (PDF)
- Concert Genetic Testing: Prenatal and Preconception Carrier Screening (V2.2023) (PDF)
- Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss (V2.2023) (PDF)
- Concert Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders (V2.2023) (PDF)
- Concert Genetics Oncology: Algorithmic Testing (V2.2023) (PDF)
- Concert Genetics Oncology: Cancer Screening (V2.2023) (PDF)
- Concert Genetics Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) (V2.2023) (PDF)
- Concert Genetics Oncology: Cytogenetic Testing (V2.2023) (PDF)
- Concert Genetics Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies (V2.2023) (PDF)
- Cosmetic and Reconstructive Procedures (CP.MP.31) (PDF)
- Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201) (PDF)
- Diaphragmatic/Phrenic Nerve Stimulation (CP.MP.203) (PDF)
- Disc Decompression Procedures (CP.MP.114) (PDF)
- Discography (CP.MP.115) (PDF)
- Donor Lymphocyte Infusion (CP.MP.101) (PDF)
- Durable Medical Equipment and Orthotics and Prosthetics Guidelines (CP.MP.107) (PDF)
- Experimental Technologies (CP.MP.36) (PDF)
- Facet Joint Interventions (CP.MP.171) (PDF)
- Facility-based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248) (PDF)
- Fecal Incontinence Treatments (CP.MP.137) (PDF)
- Ferriscan R2-MRI (CP.MP.53) (PDF)
- Fertility Preservation (CP.MP.130) (PDF)
- Fetal Surgery in Utero for Prenatally Diagnosed Malformations (CP.MP.129) (PDF)
- Functional MRI (CP.MP.43) (PDF)
- Gastric Electrical Stimulation (CP.MP.40) (PDF)
- Gender-Affirming Procedures (CP.MP.95) (PDF)
- Heart-Lung Transplant (CP.MP.132) (PDF)
- Home Births (CP.MP.136) (PDF)
- Home Ventilators (CP.MP.184) (PDF)
- Hospice Services (CP.MP.54) (PDF)
- Hyperhidrosis Treatments (CP.MP.62) (PDF)
- Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180) (PDF)
- Implantable Intrathecal or Epidural Pain Pump (CP.MP.173) (PDF)
- Implantable Loop Recorder (CP.MP.243) (PDF)
- Implantable Wireless Pulmonary Artery Pressure Monitoring (CP.MP.160) (PDF)
- Intensity-Modulated Radiotherapy (CP.MP.69) (PDF)
- Intestinal and Multivisceral Transplant (CP.MP.58) (PDF)
- Intradiscal Steroid Injections for Pain Management (CP.MP.167) (PDF)
- IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (CP.MP.61) (PDF)
- Lantidra (Donislecel): Allogenic Pancreatic Islet Cellular Therapy (CP.MP.250) (PDF)
- Liposuction for Lipedema (CP.MP.244) (PDF)
- Long Term Care Placement (CP.MP.71) (PDF)
- Lung Transplantation (CP.MP.57) (PDF)
- Lysis of Epidural Lesions (CP.MP.116) (PDF)
- Multiple Sleep Latency Testing (CP.MP.24) (PDF)
- Neonatal Abstinence Syndrome Guidelines (CP.MP.86) (PDF)
- Neonatal Sepsis Management (CP.MP.85) (PDF)
- Nerve Blocks and Neurolysis for Pain Management (CP.MP.170) (PDF)
- Neuromuscular and Peroneal Nerve Electrical Stimulation (NMES) (CP.MP.48) (PDF)
- NICU Apnea Bradycardia (CP.MP.82) (PDF)
- NICU Discharge Guidelines (CP.MP.81) (PDF)
- Nonmyeloablative Allogeneic Stem Cell Transplants (CP.MP.141) (PDF)
- Obstetrical Home Care Program (CP.MP.91) (PDF)
- Omisirge (Omidubicel): Nicotinamide-Modified Allogeneic Hematopoietic Progenitor Cell Therapy (CP.MP.249) (PDF)
- Orthognathic Surgery (CP.MP.202) (PDF)
- Osteogenic Stimulation (CP.MP.194) (PDF)
- Outpatient Cardiac Rehabilitation (CP.MP.176) (PDF)
- Outpatient Oxygen Use (CP.MP.190) (PDF)
- Pancreas Transplantation (CP.MP.102) (PDF)
- Panniculectomy (CP.MP.109) (PDF)
- Pediatric Heart Transplant (CP.MP.138) (PDF)
- Pediatric Kidney Transplant (CP.MP.246) (PDF)
- Pediatric Liver Transplant (CP.MP.120) (PDF)
- Pediatric Oral Function Therapy (CP.MP.188) (PDF)
- Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (CP.MP.147) (PDF)
- Phototherapy for Neonatal Hyperbilirubinemia (CP.MP.150) (PDF)
- Physical, Occupational, and Speech Therapy Services (CP.MP.49) (PDF)
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction (CP.MP.133) (PDF)
- Proton and Neutron Beam Therapies (CP.MP.70) (PDF)
- Reduction Mammoplasty and Gynecomastia Surgery (CP.MP.51) (PDF)
- Repair of Nasal Valve Compromise (CP.MP.210) (PDF)
- Sacroiliac Joint Fusion (CP.MP.126) (PDF)
- Sacroiliac Joint Interventions for Pain Management (CP.MP.166) (PDF)
- Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders (CP.MP.146) (PDF)
- Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174) (PDF)
- Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections (CP.MP.165) (PDF)
- Short Inpatient Hospital Stay (CP.MP.182) (PDF)
- Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) (PDF)
- Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117) (PDF)
- Stereotactic Body Radiation Therapy (CP.MP.22) (PDF)
- Tandem Transplant (CP.MP.162) (PDF)
- Therapeutic Utilization of Inhaled Nitric Oxide (CP.MP.87) (PDF)
- Total Artificial Heart (CP.MP.127) (PDF)
- Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (CP.MP.163) (PDF)
- Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (CP.BH.200) (PDF)
- Transplant Service Documentation Requirements (CP.MP.247) (PDF)
- Trigger Point Injections for Pain Management (CP.MP.169) (PDF)
- Urinary Incontinence Devices and Treatments (CP.MP.142) (PDF)
- Vagus Nerve Stimulation (CP.MP.12) (PDF)
- Ventricular Assist Devices (CP.MP.46) (PDF)
Payment Policies
Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the Ambetter of Illinois Payment Policy Manual apply with respect to Ambetter of Illinois members. Policies in the Ambetter of Illinois Payment Policy Manual may have either a Ambetter of Illinois or a “Centene” heading. In addition, Ambetter of Illinois may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Ambetter of Illinois.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
- 30 Day Readmission (PDF) Effective Date: 2/1/2017
- Non-Emergent ER Services (Leveling of ER) (PDF) Effective Date: 10/8/2017
- Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF) Effective Date: 10/1/2018
- Physician's Office Lab Testing (POLT) (PDF) Effective Date: 10/8/2017
- Robotic Surgery (PDF) Effective Date: 9/1/2017
- Status "P" Bundled Services (PDF) Effective Date: 4/1/2017
- Urine Specimen Validity Testing (PDF) Effective Date: 10/8/2017
- Wheelchairs and Accessories (PDF) Effective Date: 8/12/2016